When an auditor reviews your mental health records, they’re looking for specific elements that will justify the money they paid you for your services. And if they can’t check off every box, they won’t hesitate to recoup your reimbursement.
To anticipate exactly what auditors are looking for in your mental health records, check these 10 potential recoupment triggers.
1. Not Using Behavioral Language to Show Functional Impairments
When you see a patient, it’s not enough to document their symptoms and diagnosis. Every patient presents with slightly different nuances, and insurers don’t want you to simply document the symptoms leading to a diagnosis—they want you to document for a real person. That means you need to document behavioral examples.
If you can’t come up with behavioral examples from what the patient tells you, it’s a good idea to ask questions. For instance, “What does the depression make you do or not do?”
They may tell you more about their behaviors at that point, which you must document. For instance, “The patient is unable to get out of bed unless she has to use the bathroom or walk her dog. She has stopped eating except the occasional can of soup, and has stopped brushing her teeth. She won’t answer calls but she does talk to her mother in person when she comes by every afternoon.”
2. Absence of Measurable Objectives
You’re likely to work with your patients on objectives that will help them meet their goals, and you should be documenting what those objectives are and how you’re measuring progress toward them.
For instance, suppose the patient isn’t able to fall asleep easily five nights out of seven nights, so to help remedy that, the patient agrees to practice mindfulness every day and turn off electronics one hour before bed with the goal of falling asleep ten minutes earlier per week every week until hitting that objective. This is easily measurable, and simple to document.
3. Failing to Document Progress
Once you’ve created your measurable objectives, you must document the progress that the patient is making toward them. And you can’t simply say “Patient is making moderate progress” or “No progress noted.” You must document which behaviors are changing.
For instance, “The patient noted that she was able to fall asleep by 9:30 p.m. for the first time in a year. She took two showers this week, compared to the prior week, when she didn’t take any.”
4. Not Fulfilling the Golden Thread
The golden thread means you’re demonstrating continuity from the beginning of the note to the end of it. Someone should be able to read your documentation and understand why the patient presented, how their issues were affecting their life, what the objectives were, what the progress has been, and what the adjusted goals are in a cohesive way.
5. Lack of Start and Stop Time Documentation
The time you start therapy and the time you end it must be documented in every medical record. Not only is it required, but it can also protect you because it validates the codes you’re reporting, which are time-based.
6. Failing to Document the Patient Details on Every Page of Every Document
Even if it seems redundant, you must have your name, the patient’s name and date of birth, as well as your name and the date of service on every page of every document. In an EHR, this is automatically done and will appear when you print it out, but if you create your own template, don’t forget to include it.
7. The Symptoms and Treatment Don’t Support the Diagnosis
In every mental health note, the symptoms and treatment must support the diagnosis. This may sound simple, but many clinicians don’t do it properly, making it one of the top three causes for recoupment.
For instance, suppose a therapist documents a diagnosis of major depressive disorder, but all the behaviors and symptoms the therapist documents involve OCD instead of depression. If the insurer can’t see a connection between the treatment, diagnosis and symptoms, they won’t be able to justify your services.
8. The Notes Are Illegible
Having illegible notes is the equivalent of having no notes at all. If an auditor can’t read them, you will be left having to pay back every cent you collected. If you’re guilty of creating illegible notes, it’s important to work on your handwriting or shift to typed or dictated documentation.
9. The Documentation Is Missing Your Signature
You must sign and date all documentation, and include your licensure on it as well—even if your name and licensure is at the top of your note. Although this sounds simple, it’s also one of the biggest reasons payers take back therapists’ pay, so it’s important to adhere to.
10. Using Templates with Predefined Check Boxes, Answers
Some therapists use documentation templates that include predefined answers, with check boxes next to them for recording a patient’s symptoms, diagnoses and other options. These types of templates don’t provide sufficient information to demonstrate that medical necessity criteria have been met, and should be avoided.
There’s a lot more to know about maintaining thorough mental health documentation. Expert Beth Rontal, LICSW can walk you through the most important issues during her 60-minute online training session, “Stop Your Therapy Progress Notes from Triggering Payer Audits.” Register today!
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